VASCULAR WOUNDS

PATHOPHYSIOLOGY AND MANAGEMENT

Lucy Stopher, A/CNS Vascular Surgery

“...it is best to think of a wound not as a

disease, but rather as a manifestation

of disease.” Joe McCulloch

In order to manage wounds effectively, it is

essential to manage the underlying cause.

CIRCULATORY SYSTEMS

Arterial

Venous

Lymphatic

Arterial Insufficiency

Atherosclerosis develops in the arteries

supplying the legs

This results in diminished blood supply to the

tissue

Wounds caused by trauma or pressure are

much less likely to heal when blood supply is

diminished

Arterial Insufficiency

Signs of Arterial Insufficiency

Pale, cool skin

Minimal or no hair growth

Diminished pulses

Pain – usually described as cramping muscles

or pain in the foot either at rest or after

walking/exercise (claudication)

Stages of Arterial Insufficiency

Arterial Insufficiency

Characteristics of arterial ulcers

Arterial ulcers are usually:

Deep and punched out

Painful, especially when elevated

Over bony prominences

Arterial Ulcers

Investigations

Noninvasive Invasive

Doppler ultrasound

ABI

Clinical Assessment

Pulses

Colour

Temperature

Movement

Sensation

Capillary refill

Hair loss

CT angiogram

MR angiogram

Diagnostic angiogram

Arterial wound management

Prior to revascularisation, wound management

should be conservative. The aim is to keep the

wound free of infection

Adequate pain relief should be provided

Once blood supply is restored moist wound

healing should be encouraged

Treatment Options

The only way to heal an arterial ulcer is to improve

the blood supply

Angioplasty/stent: A catheter is passed through

the femoral artery and an attempt is made to

balloon the narrowing's open

Bypass: A vein or synthetic graft is used to

bypass the blocked artery

Amputation is required once too much tissue is

damaged

Treatment Options

Venous Insufficiency

There are valves in the veins that open and close to push blood back up to the heart.

These valves can stop working efficiently and fluid accumulates in the lower leg, this is known as chronic venous insufficiency.

As the fluid builds up in the lower leg it puts pressure on the skin. The skin then becomes fragile and breaks down causing a non-healing ulcer.

Causes of venous insufficiency

Venous Insufficiency can be caused by:

previous DVT

varicose veins

genetics

Signs of venous insufficiency

Lower limb oedema

Hyperkeratotic skin – scale build up

Haemosiderin staining – brown staining on the

skin

Large, shallow ulcer

Often minimal complaints of pain

Venous ulcers

Investigations

Ultrasound of the veins is required to assess

whether the deep or superficial veins are the

cause of the non-healing ulcer.

Management of venous ulcers

Compression bandaging is essential to decrease

oedema and allow the ulcer to heal

Moist wound healing should be maintained

Infection should be managed with antimicrobial

dressings

The patient should be encourage to walk

regularly to promote the use of the calf muscle

pump to decrease oedema

Management of venous ulcers

Treatment options

If the superficial veins are incompetent they can

be surgically removed or treated to prevent

further ulceration

If the deep veins are incompetent the only

management is compression – bandages if

there is an ulcer, then lifelong compression

stockings once the ulcer has healed

Neuropathic Ulcers

Peripheral neuropathy is damage to the

peripheral nerves that causes change in

sensation and strength

This is mainly caused by diabetes

Neuropathic ulcers develop because the foot

becomes numb and the patient doesn’t notice

ongoing pressure causing an ulcer

Testing for neuropathy

Characteristics of Neuropathic Ulcers

Bony and/or plantar aspect of foot

Surrounding built up callous

Malodour common

Neuropathic Ulcers

Management of neuropathic ulcers

Offloading the weight from the wound is crucial

to wound healing. Podiatrists can provide

footwear to assist with this.

Moist wound healing should be maintained

unless blood supply is diminished.

Diabetic Foot ulcers develop due to:

Impaired healing

Neuropathy

Arterial insufficiency

Diabetic foot ulcers

Usually develop from trauma/pressure

Require aggressive management to:

Offload pressure

Prevent infection

Fix any arterial insufficiency

Amputation is performed once the bone is

infected (osteomyelitis)

Summary

Understanding the underlying disease is

essential to heal the wound

Thorough assessment is required to diagnose

Treatment of the underlying disease will heal the

wound